What’s the Value of an Annual “Checkup”?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are annual checkups all they’re cracked up to be?

Remember Cigna’s “Doctors of America” ads?

“We are the TV Doctors of America,” says McDreamy.

“And we’re partnering with Cigna to help save lives,” says Dr. John Carter.

“By getting you to a real doctor for a checkup,” chimes in Cuddy.

But to put our “Devil’s Advocates of America” hats on: what if this annual checkup business isn’t all it’s cracked up to be?

It is reasonable to hold any potential medical test or treatment to one of three standards:

  1. It makes the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees, for starters. It could even apply to things like bone mineral density screening, sometimes referred to as “DXA,” which linked with osteoporosis treatment may make no difference in the risk of death, but clearly prevents hip, wrist, and spine fractures.

  2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolong many lives).

  3. Finally, if a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money [disclaimer: the KBGH is closely linked to Health ICT through the Medical Society of Sedgwick County, which receives CDC funding to promote things like blood pressure control, cholesterol management, and diabetes prevention].

Many of the tests and treatments medicine offers do not live up to that rubric. This may be why the Cochrane Review, which many consider the highest level of evidence in medicine, published a review in 2018 stating that “Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.” So when the TV Doctors of America say you need an annual checkup, what they surely mean is not that you need an old-fashioned sit-down with your doctor where, at the end of the visit, she gives you a “clean bill of health.” No. What I hope they mean is that you need to have access to a primary care provider. Investigators in 2019 found that every 10 additional primary care physicians per 100,000 people was associated with a 51-day increase in life expectancy, which doesn’t sound like much, but is pretty big by medical standards. Some estimate that a doctor practicing at the top of his license adds about 4.5 net years to the average patient’s life. Not too shabby.

“Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.”

What actually improves or extends someone’s life?

What the TV Doctors of America really mean is that you should have certain preventive services like immunizations and periodic screenings for health conditions that, if left untreated, can profoundly shorten your life. Most of these aren’t sexy. Probably the most effective preventive medical intervention, for example, is a simple periodic blood pressure check with medications if your blood pressure is too high. Sexier things like cancer screenings tend to have a “disease-specific” benefit, meaning they prevent you from dying of colon, prostate, cervical, breast, or lung cancers specifically, but they may not make people live longer as a whole.

If there is doubt in your company about what services you should be providing, a good place to start is with the United States Preventive Services Task Force (USPSTF), a rotating group of doctors that follows very specific rules to evaluate the risks and benefits of specific screening. Their opinion holds a lot of weight because any test given a “B” or better rating is mandated to be covered by your insurance. Examples of “A” rated services are things like tobacco use counseling and interventions, blood pressure screening in adults, and screening for cervical and colon cancers, which are all strategies that easily conform to our rubric. Cholesterol testing in people without diabetes or heart disease gets a “B.” Screening for prostate cancer in men aged 55-69 with a prostate specific antigen (PSA) test is a good example of a “C” rated service, since it has no overall mortality benefit and its disease-specific mortality benefit is largely offset by the harms that screening can cause (prostate biopsies and surgeries can cause bladder leakage and erectile dysfunction, among other things). PSA screening for prostate cancer in men aged 70 or older gets a “D” rating because it appears, in the hive mind of the USPSTF, to cause more harm than it prevents; that is, it violates rules #2 and 3.

What does this mean for employers?

How do you apply this to your workforce? Start by being an informed shopper for any workplace wellness services being offered to your company. Whenever a wellness provider tries to charge you a lot of money for offering annual “wellness checks” or “health risk assessments,” check their recommendations against the opinion of the USPSTF (or have us at KBGH check them for you). If the amount of testing they’re charging far exceeds what the experts recommend, ask them why.

Second, work on the health literacy of your employees (we can help with this). It’s hard as a patient to turn down testing or treatment your doctor offers if you don’t have the background to know what works and what doesn’t. I’m a doctor myself, and even I’ve felt vulnerable being squeezed through the gears of the medical-industrial complex.

Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general

I've had several Impossible Burgers. They're amazing

A few years ago I made a choice to eat very little meat. Everyone who comes to a this dietary decision gets there for one of several reasons. For some, it's a matter of animal welfare. For me, it was the impact of excessive meat intake on my personal health: meat, particularly red meat and processed meat like bacon, has been linked to increased risk of heart disease, cancer, and other diseases. Plus, beef in particular is astonishingly carbon-intensive; were people to forgo only red meat in favor of beans (while, mind you, continuing to eat pork and poultry), the U.S. would come very near Paris Accord carbon emissions goals, all without a change in driving habits or other energy production from fossil fuels, and without a change in efficiency. 

Giving up meat for me was astonishingly easy. I don't miss it. Were you to ask me to give up sweeteners, we'd have a problem. I like desserts more than I should, and despite my frequent screeds against bug juice, I have an occasional caffeine-free Diet Coke. But no meat? No problemo. Part of the reason for this is that we've had a big increase in the availability of meat substitutes in the past decade or so. This doesn't affect me so much as it affects people who eat with me. I can make meals that are almost meat that I can serve to carnivorous friends and family without feeling like I'm depriving them of anything. But hamburgers, the quintessential American food, have been a problem. I've tried multiple veggie patties and black bean patties. They're all mostly okay, but they're no substitute for real meat. You have to have in your mind that you're not eating a hamburger to enjoy them. You tell yourself, "This is a good veggie burger," but you can never convince yourself that you're eating a real-for-real hamburger.

Then I heard about Impossible Foods and their bleeding vegan hamburgers. I was intrigued, but there was no place near home for me to try one. But last summer I was in Houston a week or two before Hurricane Harvey. We found a Hopdoddy just west of Rice Stadium:

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This was directly adjacent to Rice's semi-famous 1/3 mile "Bike Track," whose popularity I assume is at least partly due to the apocalyptic artillery-grade roughness of the surrounding streets. Hopdoddy was pushing the Impossible Burger hard:

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But that didn't mean they didn't have the customary pile o' beef in their kitchen:

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And it didn't mean that when I ordered on the waitress wouldn't say I was "brave." But when it arrived, so far, so good:

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My burger looked like a million bucks. But I didn't get a chance to find out if my burger bled; it was well-done:

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Impossible Burger has the look and feel of beef. It has the mouthfeel of beef. It just does. For all intents and purposes from the consumer end, this is beef. I tried a bite of my son's regular patty for a taste test. I'm a bit of an unreliable witness here; my enthusiasm for meatless foods taints my impression of these things. But honestly, the only difference was that his real burger was saltier. I suspect Impossible keeps the salt content lower to avoid dryness.

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I liked the one I ate so much that I convinced my then-ten year-old daughter, a notorious carnivore, to try one. She will eat veggie patties, begrudgingly, the way somebody who's tasted whole milk will settle for almond milk on her cereal if they don't have a choice. But after tasting mine, she was enthusiastic to get her own. And she's had several since.

The primary ingredients are wheat, coconut oil, potatoes, and heme. Heme is part of the molecule that carries oxygen in your bloodstream: "hemoglobin." Impossible gets its heme in the form of soy "leghemoglobin." Their website says they chose it because of taste and lack of allergenicity. I suppose this means people won't get a rash if they eat it. Not that I knew hemoglobin allergies were a big problem.

If you're the anti-GMO type (I'm most certainly not), beware that Impossible's leghemoglobin is produced by a genetically modified yeast. But it is 100% vegan. It's not gluten-free, which is a bummer for the small fraction of the population with celiac disease. For the remaining 99% of us, it's neither here nor there. Impossible burger patties are kosher.  Halal are anticipated later this year.

My second Impossible Burger was in Washington, D.C., for a work trip. My daughter's, ironically, came with bacon:

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My wife's medium-rare (not ordered that way, but delivered that way) patty gave us a chance to taste the heme without the searing. It definitely loses something. The seared heme is important: 

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I tried to convince my daughter that the tater tots were also "Impossible," but that since they were naturally made of potatoes the impossible factor was figuring out how to make them out of animals. She didn't buy it: 

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Impossible Burgers are now served in more than 1,500 restaurants. Since April, White Castle has been selling Impossible Sliders for just $1.99. After trying Impossible Burgers myself, I'm convinced that meat production in the way we've been practicing it for the past 100 years has an expiration date. We simply won't tolerate the health and environmental consequences of it when we have alternatives that are this good. I'm not here to tell you that Impossible Burgers represent any kind of achievement. Quite the contrary: as good as they are, they're just the beginning. Meatless "meat" is the worst today that it ever will be. It will only get better from here. Next phase vegetarian chicken? Faux eggs? Faux seafood